Low Back Pain or Pain of Lower Back is also known as Lumbago. Lumbago is a common disease that affects individuals of all ages. Musculoskeletal system of the lower back protects spinal cord and spinal nerves. Lumbar Musculoskeletal System includes Paravertebral muscles (muscular system) and vertebral column (skeletal system). Paravertebral muscles protects spinal cord by preventing abnormal movements of the back by coordinating contractions of various muscles in direction of movements and also prevents extended bending in any particular direction during fall or accident. Solid structure of vertebral column protects spinal cord. Spinal cord is confined within spinal canal, which is surrounded by vertebrae. Low back pain or Lumbago includes pain in lower back, pain spread over buttocks and also the pain is referred to lower leg. Low Back Pain or Lumbago is also known as Sciatica Pain, Radicular Pain or Radiculopathy.

  • Sciatica- Sciatic pain is the severe leg pain that spreads along the dermatome of multiple lumbar spinal nerves.
  • Radicular Pain- Leg pain along the lumbar nerve is known as radicular pain. Pain may be spread over one or more of lumbar spinal nerve.
  • Radiculopathy- Radiculopathy is the group of symptoms which includes radicular pain with tingling, numbness and muscle weakness.

Anatomy of Lower Back:

Anatomical Structures of Lower Back Are As Follows

  1. Vertebral Column
  2. Paravertebral Muscles
  3. Paravertebral Tendons
  4. Ligaments

a) Vertebral Column Includes

Spinal Cord within Spinal Canal

  • Spinal Canal
  • Spinal Foramina
  • Lumbar Disc
  • Facet Joint

Pedicles Facet Joint

b) and c) Muscles and Tendon of Lower Back

Muscular Anatomy of the Back

  • Latissimus Dorsi Muscle
  • Erector Spinae Muscle
  1. Ileocostalis
  2. Longissimus
  3. Spinalis
  • Serratus Posterior Inferior Muscle
  • Thoracolumbar Fascia
  • Quadratus Lumborum Muscle
  • External Obliques and Internal Oblique Muscles

Tendon of Lower Back

d) Ligaments of Lower Back

  • Anterior Longitudinal Ligament
  • Posterior Longitudinal Ligament
  • Interspinous ligament
  • Ligamentun flavum

Causes of Low Back Pain or Lumbago

Low Back Pain or Lumbago Caused by Muscle Disorders or Diseases

  • Muscle Spasm - Persistent Muscle Spasm can cause low back pain or lumbago
  • Muscle Tear: Most of the low back pain or lumbago is caused by microscopic muscle tear or injury. Pain is often mild to moderate. Complete muscle tear causes severe muscle pain or lumbago.
  • Muscle Sprain - is caused by inflammation or laceration of muscle fibers, which results in moderate to severe pain.

Low Back Pain or Lumbago Caused by Tendon Abnormalities

  • Tendinitis - Tendon inflammation following repeated use of tendon causes mild to moderate pain. Pain could be intermittent or continuous.
  • Tendon Tear - Tendon tear is partial or complete. Partial tear maintains the partial continuation of muscle attachment and also adherence to adjacent bone. Complete tear causes dislocation of tendon and attached muscle from attachment to bone. Pain is severe to very severe in intensity.
  • Tendon Dislocation - Tendon is attached at one end to muscle and other end to bone. The separation of tendon from attachment to bone cause tendon dislocation resulting in floating muscle. The pain is extremely severe when muscle contracts. At rest pain is mild to moderate.

Low Back Pain or Lumbago Caused by Ligamental Abnormalities

  • Ligamental Inflammation - Ligament binds adjacent bones to form a joint. Inflammatory disease like osteoarthritis and rheumatoid arthritis causes inflammation of ligament resulting in mild to severe low back pain or lumbago.
  • Ligamental Sprain - Twist or forceful bend of back causes stretching of ligaments attached to vertebra and facet joint resulting in ligamental sprain. Ligamental sprain causes moderate to severe mid or low back pain or lumbago or neck pain.
  • Ligamental Tear - Automobile or domestic injury causes direct impact or forceful stretching of ligament, which may result in partial or complete tear of ligament. Partial ligamental tear causes mild to severe pain with activities. Complete ligamental tear causes severe to very severe low back pain or lumbago.
  • Hypertrophy of Ligament - Ligamentum flavum lies within the spinal canal. In few elderly individual ligamentum flavum becomes thick because of increased size of each fiber. The increased thickness follows narrowing of spinal canal and compression of spinal cord. The symptoms observed during early stage is moderate to severe pain and later stage severe pain is associated with tingling, numbness and weakness of extremity, back muscles.

Lower Back Pain or Lumbago Caused Due to Abnormalities of Vertebral Column:

Congenital Vertebral Column Abnormalities-

  • Scoliosis- Abnormal lateral or sideward bending vertebral column results in scoliosis and back pain.
  • Kyphosis- Abnormal flexion or forward bending of cervical, thoracic, or lumbar vertebral column results in kyphosis.
  • Lordosis- Abnormal extension or backward bending of cervical, thoracic or lumbar vertebral segment result in lordosis.

Diseases Resulting in Low Back Pain or Lumbago

  • Lumbar Disk Bulge- A disc bulge causes inflammation of disc that follows secretion of certain chemicals like prostaglandin resulting in severe low back or lumbago pain. Large disc bulge in spinal canal may cause spinal stenosis, similarly large disc occupying spinal foramina causes foraminal stenosis.
  • Lumbar Herniated Disk- Also known as slipped disc, lumbar herniated disc often causes severe pain in low back or lumbago and radicular pain along lower leg. Herniated disc during initial phase causes secretions of several chemicals that irritates spinal nerve and causes severe low back or lumbago pain. The large herniated disc may protrude into spinal canal or spinal foramina resulting in irritation or pinch of spinal nerve.
  • Lumbar Disk Rupture or Fracture- Trauma, domestic fall or auto accident may cause severe injury of disc resulting in disc fracture. The moderate to severe low back pain or lumbago is cause by fracture disc or disc inflammation.
  • Degenerative Disk Disease- Degeneration of the vertebral discs of the lower back can lead to low back pain or lumbago. Disc degeneration causes thinning of intervertebral disc resulting in foraminal and spinal stenosis.
  • Osteoporosis of Lumbar Vertebral- Osteoporosis is demineralization of bones of vertebral column. The low calcium level in bone causes fracture of body of vertebrae, lamina and pedicle.
  • Spinal Stenosis- Spinal stenosis is a narrowing of spinal canal because of hypertrophy of ligamental flavum, tumor encroachment or disc protrusion. Spinal stenosis causes pinch or irritation of spinal nerve or spinal cord resulting in low back pain or lumbago.
  • Foraminal Stenosis- Foraminal stenosis is a narrowing of spinal foramina. Foraminal stenosis causes irritation or pinch of spinal nerve, which causes moderate to severe low back pain or lumbago. Spinal foraminal stenosis is caused by following diseases-
    • Disc Bulge. Spinal nerve is irritated or pinched when foramina is encroached by bulge disc.
    • Disc Herniation. Herniated disc like disc bulge protrudes into foramina and either irritates or pinch spinal nerve.
    • Degenerative Disc Disease. Severe disc degeneration also causes foraminal narrowing.
  • Spondylolisthesis- Spondylolisthesis is a forward displacement of vertebrae over the disc. The mild or grade one spondylolisthesis causes no pain or mild low back pain. Grade 2 (moderate) or 3 (severe) slippage causes moderate to severe pain low back pain or lumbago.
  • Bone tumor (Cancer)- Primary or metastatic tumor of vertebrae may protrude into spinal canal or spinal foramina resulting in low back pain or lumbago and radicular pain. Pain is caused by pinch or irritation of spinal cord in spinal canal or spinal nerve in foramina.
  • Epidural Space Abnormalities Space Occupying Lesions- Epidural space is the outermost layer of soft tissue within spinal canal. Epidural space lies outside dura membrane. Spinal nerve lies in epidural space before passing through the foramina. Epidural space occupying diseases like abscess or blood clot (hematoma) causes irritation or pinch of spinal nerve resulting in low back pain or lumbago. Following are the epidural space occupying lesions-
    • Epidural Abscess
    • Epidural Hematoma
  • Facet (Zygopophysial) Joint Diseases Causing Low Back Pain- Facet joint is formed by a link between superior and inferior articulating process of adjacent vertebra. Superior articulating process is a bony extension of upper vertebrae and inferior articulating process is a bony extension of lower lumbar vertebra. Facet joint pain is localized over back. Diseases or disorders of facet joint resulting in low back pain or lumbago are as follows-
    • Arthritis of Lumbar Facet Joint. Osteoarthritis (most common), Rheumatoid Arthritis and Psoriatic Arthritis are some of the common causes of low back pain or lumbago
    • Facet Joint Dislocation. Facet joint dislocation is extremely rare but may result following sport injury or automobile accident. Direct impact or twist of lower back against resistance causes facet joint dislocation.
    • Fracture of Superior or Inferior Articular Process. Fracture of facet joint results in severe low back pain or lumbago. Fracture of either superior or inferior articulating process follows work injury or automobile accident.

Symptoms of Low Back Pain or Lumbago

Chronic Pain of Low Back

Pain lasting more than 3 to 6 months is known as chronic pain. Lumbago, radicular or sciatica pain is referred to lower back and lower extremity. Pain is caused by pinch of lumbar or sacral spinal nerves. Sciatica or radicular pain is caused by pinch of one of the five lumbar nerves (L1 to L5) or first sacral (S1) nerve. Nerve is pinched either within lumbar spinal canal or lumbar spinal foramina. Nerve may be pinched outside spinal canal by primary cancer, metastatic cancer, hematoma (blood clot) or abscess.

Types of Low Back Pain or Lumbago

  • Lumbago (Lower Back Pain)- Lower Back Pain localized exclusively over lower back is called Lumbago. Lumbago is caused by illnesses involving paravertebral muscles and facet (zygapophyseal) joint.
  • Sciatica or Radicular Pain- Sciatica or Radicular Pain is referred to lower leg. The pain is caused by irritation of the lumbar and sacral spinal nerve. Sciatica pain is caused by pressure or squeeze of spinal nerves within spinal canal or foramina or outside foramina, also known as pinched nerve pain. Such Sciatica pain is isolated leg pain and may not be associated with pain over lower back.
  • Mixed (Lumbago and Sciatica) Lower Back Pain- Most of the lower back pain is a mixed pain. Mixed pain is pain spread over lower back (lumbago) and lower leg (Sciatica or Radicular pain). Mixed pain is caused by pinched nerve associated with illnesses of facet joint and paravertebral muscles.

Muscle Pain- Paravertebral muscle pain is often caused by muscle tear, sprain or inflammation of the muscle. Paravertebral muscle tear and sprain is seen following sports injury, automobile or work accident. Pain caused by diseases or injuries of the muscle is mostly felt over lower back. Muscle pains mostly do not refer to leg like sciatica or radicular pain.

Ligament or Tendon Pain- Several ligaments and tendon support vertebral column. Injury or inflammation of ligament or tendon causes severe back pain. Tear and sprain of the ligament or tendon is often seen following sports injury, automobile or work accident. Pain is mostly spread over lower back. Sciatic or radicular pain is not observed following ligamental or tendon injury or inflammation.

Urinary (Bladder) and Bowel Incontinence- Sacral nerve injury may cause urinary and bowel incontinence along with leg pain. Symptoms of incontinence are often masked during initial phase because of severe intractable pain following injury. Lower back pain is often associated with bowel or bladder incontinence in lumbar and sacral spinal injury

Insomnia- Chronic lower back pain is often associated with insomnia, since patient is often unable to find comfortable position in bed.

Fatigue- Patient often complaints of weaknesses and fatigue as a result of severe pain.

Anxiety- Severe pain causes short or long-term disability and often do not respond to pain medications. Long term pain and sufferings may result in cognitive disorder such as anxiety.

Depression- Few patients suffer with long-term depression because of restrictions of activities and unable to perform daily activities.

Signs of Low Back Pain or Lumbago

Paravertebral Muscle Spasm- Palpation of paravertebral muscles during examinations reveals muscle contraction and spasm. Muscle spasm is seen following muscle or tendon disorder. In most cases of pinch nerve pain, paravertebral muscle spasm is observed as protective reflex. Persistent muscle spasm or muscle contraction prevents occurrence of severe pain resulting from movement of lower back.

Fever- Fever may be associated with lower back pain. Fever is often caused by epidural or paravertebral abscess.

Anatomical Abnormalities of Vertebral Column- Anatomical abnormality of vertebral column often causes severe lower back pain. Congenital abnormality is not caused by injury or inflammation of the vertebral column and surrounding soft tissue. Weight distribution along the vertebral column depends on normal shape of the spine. Congenital disorders of vertebral column like scoliosis, kyphosis or lordosis presents abnormal angle of weight distribution. Inappropriate angle of weight distribution causes additional stress of muscles, tendon and ligaments resulting in severe pain.

Structural Abnormality Disorders of Vertebral Column

    • Scoliosis- Abnormal exaggerated lateral bend of vertebral column.

Scoliosis- Abnormal exaggerated lateral bend of vertebral column.

    • Lordosis- Abnormal exaggerated backward bend of vertebral column.

Lordosis- Abnormal exaggerated backward bend of vertebral column.

    • Kyphosis- Abnormal exaggerated forward bend of vertebral column.

Kyphosis- Abnormal exaggerated forward bend of vertebral column.

Investigations to Diagnose Low Back Pain or Lumbago

X-Ray- Is the Initial preferred diagnostic tool for lower back pain or lumbago. Following illnesses are diagnosed using X-Ray examination.

  • Osteoporosis
  • Fracture- Body of Vertebrae, Lamina And Facet Joint
  • Dislocation- Facet Joint
  • Facet Joint Arthritis
  • Multiple Myeloma

MRI- MRI is an investigation of choice to evaluate the cause of lower back pain or lumbago.

Indications for MRI Are As Follows

  • Continuous Pain- Lumbago or Low Back Pain if not responding to initial conservative treatment.
  • Negative X-Ray Finding- Pain is persistent for over 3 to 4 week.

Following Disorders Which Can Be Causing Low Back Pain or Lumbago Are Diagnosed Using MRI

  • Osteoporosis
  • Fracture Vertebral Body, Lamina And Facet Joint
  • Dislocation of Facet Joint
  • Facet Joint Abnormalities Caused By Facet Joint Arthritis Or Arthropathy
  • Ligamentum Flavum Hypertrophy
  • Multiple Myeloma
  • Metastatic Cancer
  • Epidural Hematoma
  • Epidural Abscess

CAT Scan- Computerized Tomography Scan (CAT) is alternative study to MRI. CAT Scan helps in identifying the following disorders that could be causing low back or lumbago-

  • Osteoporosis
  • Fracture- Body of Vertebrae, Lamina and Facet Joint.
  • Dislocation- Facet Joint
  • Facet Joint Arthritis
  • Ligamentum Flavum Hypertrophy
  • Multiple Myeloma
  • Metastatic Cancer
  • Epidural Hematoma
  • Epidural Abscess

Ultrasound Study: Following disorders that could be causing low back pain or are diagnosed using Ultrasound study

  • Multiple Myeloma
  • Metastatic Cancer
  • Epidural Hematoma
  • Epidural Abscess

Bone Density Test- Helps in Identifying the following causes of low back pain or lumbago -

  • Osteoporosis
  • Fracture- Body of Vertebrae, Lamina And Facet Joint
  • Dislocation- Facet Joint

Blood Examination

  • White Blood Cell Count (WBC)- WBC is increased during active phase of active infection. Increase WBC is observed in patient suffering with epidural abscess.
  • Rheumatoid Factors (RF) - Positive rheumatoid factors in blood suggest lower back pain may be caused by rheumatoid arthritis of facet joint.
  • HLA-B27 Genetic Marker- Test is positive in inflammatory facet joint diseases caused by Psoriatic hip joint disease, ankylosing spondylitis and Reiter's syndrome.

Treatment for Low Back Pain or Lumbago

  1. Conservative Treatment for Lower Back Pain or Lumbago

    • Heat
    • Cold Compression Therapy,
    • Weight Loss
    • Exercise or Yoga Therapy.
  2. Specific Treatment for Low Back Pain or Lumbago

    Treatment for Chronic Low Back Pain or Lumbago

    • NSAIDs
    • Opioids- Is Indicated if NSAIDs are not effective to relieve back pain or lumbago
    • Antidepressant Analgesics- Indicated to treat neuropathic pain and pain not responding to opioids.
    • Antiepileptic Analgesics- Treats neuropathic pain and pain not responding to opioids.

    Treatment for Inflammation: Anti-inflammatory Medications to Treat Low Back Pain or Lumbago

    • NSAIDs
    • Corticosteroids Tablets or Injection

    DMARDs for Chronic Pain

    Disease-Modifying Anti-Rheumatic Drugs(DMARDs) are used to slow the progress of the facet joint arthritis caused by psoriatic or rheumatoid arthritis. DMARD prevents permanent damage of the synovial membrane of the joint and ligaments. Following medications are often used as DMARDs to treat low back pain or lumbago

    • Methotrexate (Trexall)
    • Leflunomide (Arava)
    • Hydroxychloroquine (Plaquenil)
    • Sulfasalazine (Azulfidine)
    • Etanercept (Enbrel)
    • Infliximab (Remicade)
    • Adalimumab (Humira)
    • Golimumab (Simponi)
    • Certolizumab (Cimzia)

    Medications to Treat Muscle Spasm That Could be The Cause of Low Back Pain or Lumbago

    Low Back Muscle Spasm is treated with muscle relaxants. Following muscle relaxants are often used-

    • Baclofen
    • Flexeril
    • Skelaxin
    • Robaxin
  3. Physical Therapy (PT) For Low Back Pain or Lumbago

    PT is indicated for following clinical manifestations

    • Pain
    • Muscle Spasm
    • Stiffness of Lower Back
  4. Interventional Therapy for Low Back Pain or Lumbago

    • Corticosteroid Epidural Injection.
    • Corticosteroid Facet Joint Injection.
    • Facet nerve ablation using radiofrequency or cryo ablation.
    • Placement of spinal cord stimulator in epidural space to block and modulate pain impulses.
    • Insertion of intrathecal catheter and subcutaneous Morphine Pump to deliver opioids in Cerebral Spinal Fluid (CSF).
  5. Surgery for Low Back Pain or Lumbago

    Indication for Surgery to Treat Low Back Pain or Lumbago

    • Last Option of Treatment.
    • Failed Conservative Treatment.
    • Pain Is Not Relieved With Medications, Physical Therapy And Interventional Pain Therapy.

    Surgical Options For Low Back Pain or Lumbago

    • Percutaneous Discectomy
    • Open Discectomy
    • Partial Laminectomy
    • Total Laminectomy
    • Cages Placement Or Artificial Disc Placement
    • Spinal Fusion And Instrumentation.

Also Watch:

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: August 8, 2017

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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